Provider Demographics
NPI:1477389690
Name:PENICK, TESSA MARIE
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:MARIE
Last Name:PENICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 WRANGLER RDG APT 103
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2684
Mailing Address - Country:US
Mailing Address - Phone:314-570-9887
Mailing Address - Fax:
Practice Address - Street 1:610 VINELAND SCHOOL RD
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2561
Practice Address - Country:US
Practice Address - Phone:636-586-1000
Practice Address - Fax:636-586-1009
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021011245224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant